1.	Phacoemulsification (phaco)
2.	Extracapsular cataract extraction (ECCE)

back to top

 

Outcome measurements (CUSUM parameters)

1.	Posterior capsular rupture (PCR)
2.	Postoperative refracted visual acuity by 12 weeks post-op, excluding patients with pre-existing ocular co-morbidity
3.	Surgical-induced astigmatism

back to top

 

Standard of performance

Standards are based on national average from the CSR findings.

	Outcomes	Acceptable performance (P1)	Unacceptable performance (P2)
1.	Rate of PCR for both ECCE and Phaco	<5%	>10%
2.	Post-operative refracted visual acuity 6/12 or better by 12 weeks post-operatively
	- ECCE	>80%	<64%
	- Phaco	>85%	<82%
3.	Surgical-induced astigmatism recorded in refraction by 12 weeks post-operatively
	- ECCE	< 3 diopters cylinder power	> 5 diopters cylinder power
	- Phaco	< one diopter cylinder power	> 2 diopters cylinder power

 

back to top

 

Exclusion Criteria /Filter

Post-operative refracted visual outcome charting – exclude patients with pre-existing ocular co-morbidity
PCR and surgically induced astigmatism –no exclusion criteria

back to top

 

Pre-requisite of eCUSUM

1. Ensure complete records of patients who had cataract surgery are entered into cataract surgery registry (CSR) i.e. pre-clerking, operative records particularly intra-operative complications and post-operative refracted vision. For patients who do not have post-operative refracted vision but their unaided or pin hole vision is 6/12 or better, you can put this vision in the refracted vision column.

2. As CUSUM monitoring is on specific individual surgeon, there can only be one surgeon‘s name entered in the operative record in CSR web application. The main surgeon‘s name should be entered. If both contributed to the surgery equally, the one who has created the intra-operative complication, if any, should be entered as the surgeon.

3. When entering data to CSR web application, surgeons’ names are to be selected from the pull down list. No free text entry of names is allowed to avoid spelling mistake or same surgeon with different spelling of names.
   

   

   back to top

Use of CUSUM

1. All surgeons
   Surgeons whose patients they operated on have records in the CSR can view his/ her CUSUM chart for self monitoring.
    

2. Trainee under supervision
   CUSUM charts of trainees shall be monitored by their supervisors and head of departments. Trainees include doctors in the Postgraduate Ophthalmology training, service medical officers and gazetting specialists. Supervisors will see charts belonging to trainees assigned to them. Heads of departments will be able to review charts belonging to all the trainees and gazetting specialists.

   
   

   

   back to top

Instruction

Steps in eCUSUM charting and viewing

Step	Function/ Icon on eCUSUM	Descriptions
0	Log on	Go to NED website and click on to eCUSUM Or go straight to https://app.acrm.org.my/eCUSUM Type your username (same as NED web application username) and password (default as cusum). Change your password after the first log-in
1	ID and Select Procedure	Ensure you are the surgeon. Select the procedures, either ECCE or phaco.
2	Preview Data	Check if data are correct and complete, e.g. check that all the procedures are performed by you and data are complete. If there are missing outcome data, do retrieve patients’ note and update data in CSR web application.
3	Select Outcome	Select either PCR or post- op (12 weeks) visual acuity or astigmatism
4	Select Standard	As default
5	Filter	For post-op vision, do filter out patients with pre-existing ocular co-morbidity For PCR and surgically induced astigmatism, select all subgroups Select date. If no date is selected, CUSUM will chart all the procedures performed. The later is preferred to view the overall trend.
6	Chart	Click Chart and user will be able to see his/her CUSUM chart and patient’s data below the chart. Users can save their charts by 1. Click on ‘Select a format’ - Excel or PDF format [Excel is preferred to enable data review using sort and search functions] 2. Then click ‘ Export’ 3. Save in individual’s folder. Trainees can send these documents to supervisors as well.
7	Show data	These are data on procedures being charted.
8	Show Excluded Data	These are procedures which are being excluded, mainly those with missing values. With this list, users can go to CSR web application to update the missing values.
9	Submit Chart	This icon will only appear on trainees log on. By clicking on submit, an auto-generated email will be sent to the supervisors and the trainees’ charts will be seen on the supervisors log-on.
10	Review Trainees’ Chart	This icon will only appear on supervisor’s log- on. Supervisor will see charts belonging to trainees assigned to her/him. Heads of departments will be able to review charts belonging to all the trainees and gazetting specialists.
	Other instruction	When charting, user has to click one step after another in a forward direction without skipping a step. When returning to other parameters, user can go straight to step 3 : select outcome.

back to top

 

How to interpret CUSUM charts?

Each event is represented as a dot on the chart. Surgeons with surgical performance within the acceptable standard will have their charts displayed along horizontal lines with no up-peak or with peaks which are between 2 decision intervals (horizontal lines drawn across the chart).

Surgeons with surgical performance outside the acceptable standard will have charts which cross the decision intervals. Once the chart has crossed a decision interval, the chart will not return to X axis. If there is no more failure, the chart slopes downward and flattens at the previous decision interval. When the chart levels off, that means the surgeon has improved his skill and has overcome the learning curve.

However, if the chart goes upward and crosses a few decision intervals, the surgeons should seek advice on ways to improve their surgical performance.
 

Key Points in interpretation 

Chart crosses horizontal lines when the standard of performance is outside the defined standard.

Important to see the pattern:
1. Leveling of chart after an initial upward trend indicates the surgeon has overcome the learning curve
2. Continuous upward trend crossing many decision intervals indicate poor performance needing intervention.
3. Surgeon should review detail of patients for each unsuccessful performance to determine the reasons for failure and carry out corrective or remedial action.

back to top

 

Example of CUSUM charts 

1. Posterior capsular rupture (PCR)

This chart is initially flat as there is no PCR. With 3 occurrences of PCR, the chart crossed one decision interval. Following that there are a total of 6 PCR but occurring intermittently and the chart stays within 2 decision interval, denotes acceptable performance during this period.

 

 

 

 

 

 

 

 

 

2. Post-operative refracted vision among patient without pre-existing ocular co-morbidity

This chart reflects a typical learning curve, with initial series of unsuccessful events follows by flattening or leveling of curve. It is thus important to see the pattern of chart, i.e. upward slope, downward slope or leveling of slopes.

back to top

 

Making CUSUM monitoring meaningful

1. What is the role of trainees?
   Trainees should review their own charts, ensure data is accurate and complete, and submit the chat to his/her supervisor at a regular interval, at least once in 3 months.
   Trainees should perform an adequate number of cases to have meaningful CUSUM charts.

2. What is the role of supervisors?
   Supervisors must review trainees’ chart once they receive the email and discuss in person during the 3-monthly progress interview. Advice and guidance should be given to trainees with poor performance. For trainees with consistently poor performance, supervisors need to supervise them closely and request for more frequent CUSUM chart submission.

   

   back to top